EMR, Macros and Reporting to the Medical Community 

Reporting Like an EXPERT


The entire idea and basis of the MD Referral program is to position you as a spine expert.   There are many factors that are involved and some are often overlooked.   One of the ways to ensure that you are perceived as an expert is to look like one on paper, particularly when you report.  This can be done very easily and with little effort if you understand how to do it. 


In the reporting side of things, there are two divisions of providers and their reporting will reflect the “specificity” of their expertise.  A primary doctor will have a “type” of report and a specialist will have a certain “type” of report.  What they outline and discuss is the important point and is critical to keep in mind when you are working with the medical community.  Here are the points to be aware of when reporting.


There is a baseline to the patient encounter and the physical examination.  There are parameters that you must follow from a coding perspective in order to bill at certain levels and these levels correspond to the complexity of the patient’s case.  There are certain levels of physical examination that are appropriate for different types of patients.  For instance, if someone comes in after a motor vehicle accident with multiple complaints and you examine them with the entire examination and interview taking an hour, it is NOT appropriate to write a wellness visit note.  How do you think that you are perceived?  It looks like you cut corners and didn’t do what was appropriate for that patient.   That has been chiropractic’s problem for a long time.   What we do in our offices and what we are reporting are different.


The reporting format has the level of specialist if you want to get the attention of the medical community.  It has fit the E/M guidelines for the evaluation as well.  There will be more on the E/M coding requirements in another consultation.  A specialist has to cover the greatest amount of detail for a particular condition and put that in a report that portrays that expertise.   That is what differentiates a specialist from a therapist or a general practitioner.   Please download the Initial Evaluation Report and Re-evaluation templates from the Members Section.   This covers what is necessary.


Timely reporting is a critical part of the communication process since a referral is based on the referrer wanting information.  Producing that information timely is what builds confidence in you as a provider and shows that you respect the patient and the referral process. That is easy to do and should be done via fax, not the mail.  That decreases costs and increases efficiency. 


When reporting your assessment is the MOST important part of report when considering the MD.  This is where you are telling the reader “what is wrong with the patient”, essentially what “you are thinking”.  It should not simply be a listing of ICD-9 codes.